Síndrome de Austrian en endocarditis infecciosa: reporte de un caso y manejo médico quirúrgico exitoso / Austrian syndrome in infective endocarditis

Resumen: El Síndrome de Austrian, corresponde al cuadro clínico descrito por Robert Austrian en 1957, definido por la triada de Neumonía, Endocarditis Infecciosa (EI) y Meningitis, causado por Streptococcus pneumoniae. En la mayoría de los casos el vicio valvular presente, es la insuficiencia valvular aórtica, cuyo tratamiento médico y resolución quirúrgica de acuerdo con su gravedad, deben ser realizados precoz y oportunamente. Un paciente de 51 años, sin antecedentes de valvulopatía, con historia de poli consumo de alcohol y cocaína comenzó dos semanas previo a su ingreso hospitalario con síndrome febril, neumonía, y meningitis bacteriana por Streptococcus pneumoniae. Sus hemocultivos fueron negativos. El ecocardiograma transesofágico (ETE) fue compatible con EI valvular aórtica con insuficiencia moderada a severa. Se trató como EI a microorganismo desconocido y se efectuó un reemplazo valvular aórtico electivo con prótesis biológica a la 5° semana después de terminado el tratamiento médico antibiótico, cuyo resultado fue exitoso.

Abstract: A syndrome including Infective endocarditis, pneumonia and Meningitis caused by S pneumoniae was described by Robert Austrian in 1957. The aortic valve is affected in most cases. Medical followed by surgical treatment should be promptly implemented. The clinical case of a 51 year old man with a history of multiple drug consumption developing fever, pneumonia, and meningitis caused by S pneumoniae is presented. Blood cultures were negative and trans esophageal echocardiography showed aortic valve vegetations and moderate regurgitation. After multiple antibiotic treatment the patient underwent aortic valve replacement and recovered satisfactorily. Clinical and epidemiological characteristics of this syndrome are discussed.

Síndrome de Austrian: reporte de caso / Austrian syndrome: report of one case

Austrian syndrome is a triad characterized by pneumonia, meningitis and endocarditis, as a result of a Streptococcus pneumoniae bacteremia. We report a previously healthy 49 year-old male, who consulted at the emergency care unit with a history of one week of pleuritic pain, fever leading to an altered level of consciousness and seizures. A diagnosis of community-acquired pneumonia and meningitis was reached, isolating Streptococcus pneumoniae in the cerebrospinal fluid and blood cultures. Antibiotic treatment was started but the patient had an unsatisfactory response. During hospitalization a new heart murmur was found in the physical examination. An echocardiography was performed and a massive aortic valve insufficiency was found along with vegetations and a perforation of the same valve. The valve was replaced by a prosthetic one and the patient responded satisfactorily to the surgical and antibiotic treatment, without complications.

Unusual case of non-resolving necrotizing pneumonia: A last resort measure for cure.

To our knowledge, this is an unusual case of a community-acquired pneumonia (CAP) with sepsis secondary to Streptococcus pneumoniae that required lung resection for a non-resolving consolidation. A 74 year old previously healthy woman, presented with acute fever, chills and pleuritic chest pain in Emergency Department (ED). A diagnosis of CAP was established with a Pneumonia Severity Index CURB-65 score of 5/5. In the ER, she was promptly and appropriately managed with antibiotics and aggressive supportive therapy. She remained on ten days of intravenous antibiotics. However, 48 hours post antibiotic course, she returned to ER with fever and signs of sepsis. Despite timely and appropriate management, the consolidated lobe remained the focus of sepsis for over four weeks. The patient recovered after the offending lobe was resected. Histopathology of the lung tissue revealed acute and chronic inflammation. However, no malignancy, bacterial infection or broncho-pleural fistula was found. Eighteen months post-surgery, the patient remains well.

Lung decortication and lobectomy in a child with unrepaired tetralogy of fallot.

Patients with uncorrected tetralogy of Fallot (TOF) have been reported as undergoing emergency noncardiac surgeries such as cesarean section, brain abscess drainage, and major abdominal surgery. The uncorrected TOF group presents a great challenge with issues related to long-term effects of chronic hypoxemia and decreased pulmonary blood flow modifying patient physiology. We report a rare case of a child with uncorrected TOF with necrotizing streptococcal pneumonia complicated by empyema and bronchopleural fistula. The child successfully underwent lung decortication and right middle lobectomy in the first stage followed by an intracardiac repair (ICR) 15 days later. This staged approach was directed at controlling the infective focus, improving the pulmonary status, and following it up with a definitive ICR electively.

Renal infarction as a presentation of Austrian syndrome: thromboembolic phenomenon of pneumococcal endocarditis.

A 52-year-old unvaccinated and splenectomized man presented with fever, altered sensorium, bilateral flank pain and chest discomfort accompanied with paroxysmal atrial fibrillation with a rapid ventricular response. An abdominal computed tomography scan was performed, which revealed a right renal infarct and splenosis. Transthoracic echocardiography was performed, which demonstrated an echodense structure on the mitral valve with mitral regurgitation and a vegetation on the aortic valve with aortic regurgitation. Subsequently, he was found to have pneumococcal infective endocarditis, pneumococcal pneumonia and bacterial meningitis, namely Austrian syndrome. He underwent an early aortic valve and mitral valve repair but still had a poor clinical outcome. Renal infarction has a mortality of approximately 13.2%, which is strongly influenced by the underlying diseases and infectious complications. Medical and surgical treatment initiated in a timely manner is often inadequate. The authors report the first case of Austrian syndrome presenting with renal infarction as a clue to an embolic event associated with infective endocarditis in this study.

Current evidence for the management of paediatric parapneumonic effusions.

BACKGROUND: Parapneumonic effusions (PPE) and empyema, secondary to bacterial pneumonia, are relatively uncommon but their prevalence is increasing lately. Even if their prognosis is generally good, they may still cause significant morbidity. The traditional treatment of PPE has been intravenous antibiotics and, when necessary, chest tube drainage. Open thoracotomy with decortication has usually been applied in case of failure of the traditional approach. Lately, the use of fibrinolysis and/or video-assisted thoracoscopic surgery (VATS) are utilized in the management of PPE; however, there is still little consensus on the most effective primary treatment. SCOPE: In this article our goal was to summarize, based on up-to-date evidence, all the management options for PPE available to physicians and weigh the benefits and risks of the most popular ones, in an effort to figure out which one is superior as a first-line approach in children. FINDINGS: A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed. CONCLUSION: The main steps in treatment are diagnostic thoracocentesis and imaging, small percutaneous drainage, and considering fibrinolysis in complicated PPE. In case of failure, VATS should be the surgical method to be applied.

Deep leg vein reconstruction for an isolated mycotic common iliac artery aneurysm in an HIV-positive patient.

Isolated mycotic common iliac artery aneurysms are rare, and as such, there is no consensus opinion on management. Traditional surgical options include resection with extra-anatomic bypass, placement of allograft or antibiotic treated synthetic graft, or autogenous vein reconstruction. We report the case of a 46-year-old, human immunodeficiency virus-positive male who presented with a recurrent pneumonia and new onset of right lower quadrant abdominal pain associated with right lower extremity swelling. computed tomographic scan revealed an isolated 9.5 cm right common iliac artery aneurysm with no evidence of rupture. Preoperative blood cultures grew out Streptococcus pneumoniae. Operative repair included aneurysm resection and reconstruction using an autogenous femoropopliteal vein interposition graft from the ipsilateral thigh. The patient had an uneventful recovery with resolution of his lower extremity swelling and a normal duplex exam at follow-up. Large mycotic common iliac artery aneurysms can be successfully treated with aneurysm resection and reconstruction using an autogenous femoropopliteal vein conduit. This technique obviates the need for extra-anatomic bypass or other forms of reconstruction using prosthetic material.

Rare incidence of pulmonary gangrene--algorithm of the treatment.

The pulmonary gangrene is rare and serious disease. Our experience is based on the treatment of the 2 patients with pulmonary gangrene during the last twenty years. The first and lifesaving step in the treatment of sepsis is the early removal of the necrotic tissue. Next surgery succeeds usually after one week after initial treatment. Surgical treatment continues step by step, we do not advise providing of a major anatomical resection in the initial stage of the disease. This policy is effective in the treatment of this serious disease.

Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema.

BACKGROUND: We evaluated a technique of video-assisted thoracoscopic (VAT) decortication of the visceral cortex to reexpand entrapped lung in cases of chronic postpneumonic pleural empyema. METHODS: A prospective cohort study of 48 consecutive patients with multiloculated postpneumonic pleural empyema in whom visceral pleural decortication was required was studied. The effect of VAT decortication on perioperative outcome and factors affecting its success were assessed. RESULTS: Before the introduction of VAT decortication 12 patients were treated by thoracotomy (group T). In the subsequent 36 patients VAT decortication was attempted with success in 21 (group VS) but lung expansion was not observed in 15 patients (group VF) who required thoracotomy. There was no difference in the age or sex distribution of the 3 groups. Operating time was significantly longer in group T than group VS, mean difference 30.3 minutes (p = 0.001) and postoperative hospital stay was longer in group T than group VS, mean difference 2.9 days (p = 0.004). The success of VAT decortication was not related to either the delay between onset of symptoms or hospital admission and surgery; indeed the operating time decreased with increasing preoperative delay. However, success was related to increasing operative experience (p = 0.001). CONCLUSIONS: VAT decortication is a feasible new technique to achieve lung reexpansion in chronic postpneumonic pleural empyema and has perioperative benefits over thoracotomy.

Thoracoscopy in the management of pediatric empyema.

The surgical management of empyema consists of (1) aggressive therapy with thoracotomy and decortication or (2) conservative treatment with chest tube drainage and intravenous antibiotics. Recently, Kern and Rodgers introduced thoracoscopic debridement as an adjunct to the management of children with empyema, with promising results. Hence, the authors report their experience with thoracoscopy in the management of pediatric patients with empyema. In the last years, 10 children have undergone thoracoscopic debridement (TD) for empyema. The average age was 6.9 years (range, 2 to 16). Children underwent TD an average of 14 days (range, 8 to 16) after initial presentation and 4 days (range, 2 to 6) after admission to the authors' hospital. Indications for TD were persistent requirement of supplemental oxygen and failure of conservative medical management that consisted of antibiotics and tube thoracostomy. Three children had positive pleural fluid cultures for Streptococcus pneumoniae. In all cases, preoperative ultrasound or chest computed tomography examination showed dense pleural fluid with septation. During surgery, TD allowed for lung expansion and precise chest tube placement in all patients except one who required conversion to minithoracotomy and decortication for persistent encasement with a thick pleural peel. There were no postoperative complications related to the procedure. After TD, all children had prompt clinical improvement. The patients were weaned from supplemental oxygen by postoperative day 2, and following early chest tube removal, nine children were discharged home by postoperative day 7 (range, 3 to 10). One child required further hospitalization for underlying renal failure. In the authors' hands, TD was effective in producing prompt clinical improvement in children with empyema.(ABSTRACT TRUNCATED AT 250 WORDS)

Decortication for childhood empyema. The primary provider's peccadillo.

Of the 31 children treated for empyema thoracis secondary to pneumonitis at the Loma Linda University Medical Center, Loma Linda, Calif, from 1980 to 1990, 23 responded to prompt directed antibiotic therapy coupled with drainage, usually tube thoracostomy. All patients were cured clinically; some demonstrated residual pleural reaction with chest roentgenography or computed tomography that resolved over time. Decortication was necessary in eight severely ill children; three required concurrent lung resection for abscess. Distinct from the nonoperated group, there was a pattern of initial antibiotic trials in these patients averaging 6.5 different drugs plus delayed drainage of effusions. Delay in the initiation of antibiotic therapy was six times longer for the operated vs the nonoperated group. Delay to tube thoracostomy was 18 days for the decorticated children compared with 5.4 days for the nondecorticated children. All eight children responded completely and rapidly to their decortications. Roentgenographic changes lagged considerably behind the clinical course of the child, and computed tomographic scans provided better identification of chest tube placement but little information predictive of the need for decortication. Decortication for empyema seldom is necessary when a child is treated promptly with appropriate antibiotics directed by thoracentesis findings, and drainage, usually tube thoracostomy. The criterion for decortication is persistent sepsis, not the roentgenographic appearance of the chest.

[Treatment of acute bilateral suppurative lung diseases complicated by pyopneumothorax]. / Lechenie ostrykh dvustoronnikh nagnoitel'nykh zabolevanii legkikh, oslozhnennykh piopnevmotoraksom.

An analysis of the complex treatment of 33 patients with acute bilateral suppurative diseases of the lungs complicated by pneumothorax has been made. It has been proved that early pleurectomy with resection of the lung is possible in a number of patients with such a pathology. Indications to surgery were established and a comparative analysis of conservative and surgical methods was made.

Massive pulmonary gangrene.

A 49-year-old man suffered massive necrosis of the lung subsequent to a pneumococcal lobar pneumonia. Development of massive hemoptysis required emergency lobectomy. The patient is doing well six months after surgery. Pulmonary gangrene is a rare but grave complication of the lobar pneumonia. Both pneumococcal and Klebsiella pneumonias may progress to massive pulmonary gangrene despite antibiotic treatment. Survival seems to depend on the surgical removal of the necrotic tissue, which removes the danger of sudden massive hemoptysis.